Analysis Decision to Remove the Outboard Motor Boat rental is a seasonal business, and customer service and satisfaction are essential for the success of a small business such as this one. There is an expectation on the part of clients to have their needs met. Two of the three men were repeat clients, having rented a boat earlier in the season. Although the men were aware of the hours of operation of the outfitter, they decided to prolong their stay. The outfitter may have felt obliged to meet his clients' expectations to ensure their satisfaction. As the rental office is unattended at night, the boat and the outboard motor would have remained unattended after the renters had returned. As some of the motors had been stolen in the past, the outfitter was reluctant to take a chance this time. Hence, following discussion and agreement with the renters, the outfitter removed the outboard motor with the understanding that the clients were satisfied that they could row the boat ashore. Neither the renters nor the outfitter had monitored the weather. Consequently, none of them was aware of the heavy rain forecast for that evening. It is therefore unlikely that the decision to remove the outboard motor had taken into account the potential for change in weather conditions. Factors Affecting Navigation Because the boat was not equipped with a flashlight and was not required to carry pyrotechnics, the renters had no means to visually attract the attention of passing traffic at night. Given the environment in which the ferry personnel were operating, it is unlikely that the use of a hand-held whistle would have been successful in alerting them. Because the boat was primarily intended for operation during daylight hours and in good weather conditions, it was not fitted with a radar reflector, nor was it required to be by regulations. The boat was, therefore, a poor radar target. This, in conjunction with the clutter generated by the wavelets, could account for the echo of the boat not being sighted on the radar screen. Further, as the visibility was reduced by heavy rain, darkness and overcast skies, no one on the ferry saw anything. Additionally, the noise from the ferry engine and the fact that the wheel-house windows were closed meant that the cries for help from the boat occupants were not heard in the wheel-house. The combined effect of the prevailing winds, the direction of the waves, and the current estimated at two knots in this area caused the boat to set eastward of the rental outlet. As oars were the only means of propulsion, the set towards the ferry could not be stopped despite the boat occupants' best efforts. Ergonomics of the Navigation Bridge on the ANIK On the bridge of a ship, the human-machine interface is a critical element in the work environment and the goal of ergonomics is to optimize the functioning of the vessel's control system by adapting it to human capabilities and limitations.[6] Optimization is achieved by ensuring that the layout of the instrumentation takes into consideration its importance and frequency and sequence of use. Each component is positioned so as to minimize the workload of the operator and facilitate a safe, smooth and efficient operation. To monitor the navigational instruments and to operate the main engine controls, the master of the ferry would have to face the inboard side, which is at right angles to the direction of the vessel's travel. Consequently, there would be periods when the back of the master would be towards the outboard side. Further, as the traffic in the area includes small boats which are poor radar targets, more effort would be required to maintain an efficient look-out. This would suggest that the bridge layout is such that it is not optimal for a single-person operation, especially while operating in restricted visibility at night. Emergency Communication Equipment In this instance, because neither the ferry nor the rental boat was fitted with a VHF radiotelephone, there was no way of raising an alert through a marine system in case of an emergency. There was no regime in place to ensure that the precise number of persons aboard the rental boat was readily available ashore for use in case of an emergency. Such information, together with instructions to contact MRSC Qubec, was not displayed at rental boat sites. Consequently, it could not be used effectively in case of an emergency. The rental boat was not equipped with pyrotechnics, nor was there an effective means of communicating an emergency and alerting SAR authorities. The success of a SAR mission depends upon the prompt notification of SAR authorities and the prompt tasking of SAR resources. The lack of emergency communication equipment could result in the loss of valuable time and adversely affect the success of a SAR mission. Hydroelectric Dam Hazard Despite the presence of signs warning boaters of the danger of approaching the hydroelectric dam, some boaters venture dangerously close to the turbine outlets. The dam control room is equipped with a closed-circuit video system to meet its operational needs, but none exists to warn the controller of the presence of boats in the vicinity of the dam. As the operation procedures do not call for the visual examination of the dam, the controller does not have the means to ensure that boats are clear of the outlets when the turbines are operated. The rental boat did not have the required safety equipment to operate at night and in adverse weather conditions. The outfitter's decision to allow the renters to operate the boat past the closing time of the rental office was, in part, influenced by his desire to ensure customer satisfaction. The outboard motor (4kW or less) was removed from the boat by mutual consent between the outfitter and his clients. The ferry was operated in restricted visibility at night by a single person and the on-board ergonomics were not optimal for a single-person operation. A dedicated look-out was not posted on board the ferry. The wooden boat was a poor radar target. The clutter associated with sea state and the absence of a radar reflector on the boat could account for the echo not being sighted on the radar screen of the ferry. Without a flashlight or pyrotechnics, the renters had no means to attract attention of the passing traffic at night, and the boat was not sighted by personnel aboard the ferry. The noise of the main engine and the closed wheel-house windows could account for the cries for help from the boat occupants not being heard on the navigation bridge of the ferry. The crew of the ferry was not aware of the collision with the small boat. Despite hard rowing by the renters, the boat continued to set towards the ferry, and the absence of the outboard motor reduced their ability to clear the ferry. The ferry and the boat collided in restricted visibility at night and during, or shortly after, heavy rain showers. The occupants did not wear any PFDs. The keyhole-type PFDs provided by the outfitter were not approved in Canada. The developing situation precluded them from donning the lifejackets prior to abandonment. Two of the three occupants of the boat swam to the shore and were rescued; the third succumbed to exhaustion and drowned. Valuable time was lost as there was no emergency communication equipment on board the boat. The SAR response was initiated after a passerby heard cries for help from one of the boat occupants. Information on the number of passengers on the ferry and the number of persons on board the rented boat was not readily available for prompt and effective deployment of SAR resources. The danger associated with boats operating close to the hydroelectric dam is not fully appreciated by some boaters. There was no means of alerting the hydroelectric dam controllers of the presence of boats below the dam before the turbines were operated.Findings The rental boat did not have the required safety equipment to operate at night and in adverse weather conditions. The outfitter's decision to allow the renters to operate the boat past the closing time of the rental office was, in part, influenced by his desire to ensure customer satisfaction. The outboard motor (4kW or less) was removed from the boat by mutual consent between the outfitter and his clients. The ferry was operated in restricted visibility at night by a single person and the on-board ergonomics were not optimal for a single-person operation. A dedicated look-out was not posted on board the ferry. The wooden boat was a poor radar target. The clutter associated with sea state and the absence of a radar reflector on the boat could account for the echo not being sighted on the radar screen of the ferry. Without a flashlight or pyrotechnics, the renters had no means to attract attention of the passing traffic at night, and the boat was not sighted by personnel aboard the ferry. The noise of the main engine and the closed wheel-house windows could account for the cries for help from the boat occupants not being heard on the navigation bridge of the ferry. The crew of the ferry was not aware of the collision with the small boat. Despite hard rowing by the renters, the boat continued to set towards the ferry, and the absence of the outboard motor reduced their ability to clear the ferry. The ferry and the boat collided in restricted visibility at night and during, or shortly after, heavy rain showers. The occupants did not wear any PFDs. The keyhole-type PFDs provided by the outfitter were not approved in Canada. The developing situation precluded them from donning the lifejackets prior to abandonment. Two of the three occupants of the boat swam to the shore and were rescued; the third succumbed to exhaustion and drowned. Valuable time was lost as there was no emergency communication equipment on board the boat. The SAR response was initiated after a passerby heard cries for help from one of the boat occupants. Information on the number of passengers on the ferry and the number of persons on board the rented boat was not readily available for prompt and effective deployment of SAR resources. The danger associated with boats operating close to the hydroelectric dam is not fully appreciated by some boaters. There was no means of alerting the hydroelectric dam controllers of the presence of boats below the dam before the turbines were operated. The ferry ANIK and a small open boat collided in restricted visibility because the rental boat was operated at night without an outboard motor, with no flashlight, and the wooden boat was not fitted with a radar reflector. Due to heavy rain, the boat was not sighted either visually or by radar by the navigating personnel on board the ferry. Factors contributing to the occurrence were: the layout of the navigation bridge of the ferry was not optimal for single-person operation; the lack of a dedicated look-out on the ferry; and the lack of seamanship and navigational skills of the renters.Causes and Contributing Factors The ferry ANIK and a small open boat collided in restricted visibility because the rental boat was operated at night without an outboard motor, with no flashlight, and the wooden boat was not fitted with a radar reflector. Due to heavy rain, the boat was not sighted either visually or by radar by the navigating personnel on board the ferry. Factors contributing to the occurrence were: the layout of the navigation bridge of the ferry was not optimal for single-person operation; the lack of a dedicated look-out on the ferry; and the lack of seamanship and navigational skills of the renters. Safety Action Safety Action Taken by the Office of Boating Safety The Office of Boating Safety of the Canadian Coast Guard has now completed the Rental Boat Safety Check List Standard. The aim of this standard is to improve the knowledge of operators of rental motor boats by: promoting the safe use of navigable waters; developing a safety attitude towards pleasure boating; providing a means for pleasure craft operators to demonstrate their competency; and taking knowledge content from the safe boating course. All outfitters must develop a check list of operator skills and competency as set forth in the standard. Safety Action Taken by the Outfitter Subsequent to this occurrence, the outfitter has obtained information on the Rental Boat Safety Check List Standard with a view to implementing the standard in the boat rental operations. Safety Action Taken by the Owner of the Dam The Executive level of Hydro-Qubec is aware of the dangers associated with fishing close to the dam and is making efforts to make the public aware of these dangers.